<%= error_messages_for 'adult' %>

<!--[form:adult]-->
<input type="hidden" name="adult[type]" value="adult" />

<p><label for="adult_first_contact">Date of First Contact</label><br/>
<%= date_select 'adult', 'first_contact'  %></p>

<p><label for="adult_name">Client Name</label><br/>
<%= text_field 'adult', 'name'  %></p>

<p><label for="adult_social">Social Security #</label><br/>
<%= text_field 'adult', 'social'  %></p>

<p><label for="adult_case_manager">Case Manager</label><br/>
<%= text_field 'adult', 'case_manager'  %></p>

<p><label for="adult_victimization_type">Victimization Type</label><br/>
<%= text_field 'adult', 'victimization_type'  %></p>

<p><label for="adult_primary_crime">Primary Crime</label><br/>
<%= svs_checkboxes :adult, :primary_crime, ["Sexual Assault", "Domestic Violence", "Stalking", "Unknown"], @adult[:primary_crime]  %></p>

<p><label for="adult_all_crimes_involved">All Crimes Involved</label><br/>
<%= svs_checkboxes :adult, :all_crimes_involved, ["Sexual Assault", "Domestic Violence", "Stalking", "Unknown"] %></p>
	
<p><label for="adult_met_with_cm?">Met with Case Manager</label><br/>
<%= check_box 'adult', 'met_with_cm?' %>
</p>

<!--
<p><label for="adult_followup_provided?">Followup provided?</label><br/>
<%= check_box 'adult', 'followup_provided?' %>
-->

<p><label for="adult_birthday">Birth Date</label><br/>
<%= date_select 'adult', 'birthday'  %></p>

<p><label for="adult_gender">Gender</label><br/>
<%= radio_button :adult, :gender, 'male' %> Male <br/>
<%= radio_button :adult, :gender, 'female' %> Female <br/>
</p>

<p><label for="adult_ethnic_group">Ethnic Group</label><br/>
<%= svs_checkboxes :adult, :ethnic_group, ["Caucasian", "African-American", "Asian-American", "Pacific Islander", "Hispanic", "Native American", "Multi-Racial", "Other"], @adult[:ethnic_group] %></p>

<p><label for="adult_ethnic_other">Other</label><br/>
<%= text_field 'adult', 'ethnic_group'  %></p>

<p><label for="adult_relationship_to_perp">Relationship to Perpetrator</label><br/>
<%= svs_checkboxes :adult, :relationship_to_perp, ["Ex-Partner", "Partner", "Father", "Mother", "Spouse", "Female Family Member", "Male Family Member", "Other Non-Related", "Partner"], @adult[:relationship_to_perp] %></p>

<p><label for="adult_underserved_population">Underserved Population</label><br/>
<%= svs_checkboxes :adult, :underserved_population, ["Non-English Speaking", "Mental / Emotional Illness", "Physical / Mental Illness", "Migrant Farm Worker", "LGBTQ", "Immigrant or Refugee", "Probation / Parole", "Previously Incarcerated", "Substance Abuse", "From Rural Area", "From Tribal Area", "Polygamy", "Prostitution"], @adult[:underserved_population] %></p>



<!--[eoform:adult]-->
